Coordinates the reviews for utilization and managed care in a timely manner as specified by state and federal guidelines. Conducts initial research of the standards of care associated with utilization practices and quality of care. Assists in the preparation and follow-through of cases requiring referral to Physician Reviewers.

Ensures physician review is thoroughly completed, e.g., addresses all concerns identified during the review. Prepares formal communications to all involved parties. Performs other required chart review in accordance with the contract as stipulated.

 Responsibilities:

• Abstraction and chart review for utilization and/or quality, FI referrals, focused reviews, etc.
• Utilizes case management approach and principles to conduct review
• Initiates Quality of Care Review
• Prepares case summaries and letters for proposed quality/utilization cases
• Coordinate reviews with physician consultants as directed by state and federal regulations
• Interpret physician comments of medical records. Compose letters regarding quality and utilization issues to providers based on these comments
• Initiate correspondence to health care providers regarding specific review outcomes based on physician’s review and determinations of corresponding medical record review documentation
• Reports referrals of identified cases of potential gross and flagrant violations to Case Review Services Manager, and assists with associated work-up of cases as directed
• Downloads information to tracking systems for processing
• Ensures timeliness of completed reviews, and initiated Quality Improvement Activities
• Produce reports as needed to monitor case review activities and outcomes
• Routinely conduct, perform, and report IQC in accordance with state and federal standards. Participate in continuous quality improvement methodologies as appropriate through IQC process.
• Conducts Inter-rater Reliability review of peers.
• Remains available to provide clinical expertise to issues that are not within the boundaries of the Review Specialist

Requirements:

Registered Nurse license required

Certified Coding Specialist certification preferred

Must live in Oklahoma with the ability to occassionally come to OFMQ's corporate office in Oklahoma City. (Work will be in office while training, then will be mostly remote.)

Four year nursing degree in Nurse Science from an accredited college or university and two years experience in project related field with some quality improvement or utilization review experience preferred, or a two year degree from an accredited college or university with three years experience in related clinical field or quality improvement or utilization experience, or graduate of a nursing program of less than two years with five years experience in quality improvement and clinical experience in an acute care facility.

We recognize the value of diversity in our workforce, and encourage all qualified candidates to apply. EOE: m/f/d/v

Job Type: Full-time